Biomedical subjects
Publications and source records attributed to L F Rogers.
Fracture complications as discussed in this article are those abnormalities occurring as a direct result of or in association with a fracture or dislocation. Complications with radiographic findings are stressed, although those without definite radiographic manifestations are mentioned for the sake of completeness.
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Pain in the shoulder arises from a wide variety of abnormalities. The most common cause of acute pain in the nontraumatized shoulder is calcific tendonitis or bursitis readily identified by plain film radiography. On the other hand, the evaluation of chronic pain usually requires some combination of arthrography, CT, ultrasonography, and MRI to identify the source of the patients' complaints with certainty. The shoulder is rarely the site of a monoarticular process and is infrequently the dominant site of abnormality in a generalized articular disease. Clues to generalized disease processes are sometimes evidenced by changes within the shoulder present on the chest film. The source of pain in the shoulder was often elusive and puzzling to both the clinician and radiologist prior to the development of techniques such as arthrography, CT, and MRI that allow the precise delineation of soft tissue abnormalities. The judicious use of these techniques has, in large measure, helped to solve the puzzle.
Radiographic and clinical evaluation of the relative severity of wrist versus hand involvement in 101 patients with rheumatoid arthritis revealed more severe changes in the wrists in 60%, equal involvement in wrists and hands in 37%, and more severe changes in the hands in 3%. There were severe changes in the wrists but little or no bone or joint change in the metacarpophalangeal and proximal interphalangeal joints in 43 (21%) of the 202 extremities studied. Serial examinations showed that, in time, the hand changes tended to overtake those in the wrist. Appreciation of this progression of wrist and hand changes can help the physician avoid diagnostic difficulties in a significant percentage of patients.
Hyperostosis of the sphenoid ridge or convexity of the skull associated with meningioma en plaque (MEP) is often confused with other hyperostosing conditions, such as fibrous dysplasia or osteoma. The authors present nine cases, six of them proven, of hyperostosing MEP with specific attention to the CT features. All nine cases had one or more CT features that were characteristic or suggestive of MEP. These included periosteal pattern of hyperostosis, inward bulging of the vault lesion, surface irregularity of the hyperostotic bone, and intracranial changes. The role of CT in evaluating MEP is compared with other neuroradiologic techniques. The results indicate that high-resolution CT is the neuroimaging method of choice in evaluating MEP.
In a review of 42 cases of degenerative arthritis of the cervical spine and 22 cases of cervical spine trauma with an observed anterior slippage (spondylolisthesis) or posterior slippage (retrolisthesis) of the vertebral bodies of 2 mm or more, characteristic features were observed which allowed distinction between degenerative and traumatic slippage of the cervical spine. In degenerative slippage the shape of the articular facets and width of the facet joint space may remain normal; however, in most cases the articular facets become "ground-down" with narrowing of the facet joint space and the articular facets themselves becoming thinned or ribbon-like. In traumatic slippage the articular facets will either be normally shaped or fractured and the facet joint space will be abnormally widened. Plain radiographs will usually allow this distinction to be made; however, in difficult cases polytomography may be required.
Of 412 patients who were referred and admitted with acute cervical spine injury, 58 (14%) were subsequently found to have no fracture or dislocation when evaluated at our institution. These patients had no abnormal neurological findings or severe persistent pain in the neck. Their referral was based on false positive interpretations of radiographs of the cervical spine. The radiographs in these cases are analyzed, and conditions that had led to misinterpretation are described. The radiographic differential features from true acute traumatic injury are discussed.
Eighty-eight patients over age 40 with traumatic cervical spinal cord injuries were clinically and radiographically evaluated, and comparison was made with 35 spinal cord injury patients under age 36. While most older patients sustained obvious bony and/or ligamentous damage commensurate with their neurologic findings, 25 (28%) of the 88 patients had no demonstrable bony abnormalities and 17 (20%) of the 88 patients had only minimal evidence of bony injury. Of particular interest are the patients with severe cord injuries, yet no bony abnormalities, who seem to form a distinct subgroup of the cervical spinal cord injury patient on the basis of radiographic and clinical features. Of these 25 patients, 24 (96%) had severe cervical spondylosis. Fourteen (56%) of the 25 patients were injured in falls, five (36%) of these 14 being of a seemingly trivial nature. Of the 42 patients with minimal or no demonstrable bony abnormalities, 33 (79%) were evaluated with plain tomography and no occult fractures or other significant pathology was demonstrated. Pantopaque myelography in 27 (64%) of the 42 cases revealed no extruded disk or other surgical lesion in any patient. In large measure, these injuries can be attributed to cervical spondylosis, which narrows the canal and makes the cord more susceptible to compression by the bulging ligamenta flava during hyperextension.
A retrospective review of 75 burst fractures of the spine was performed to define the radiographic features found on high-resolution CT, polytomography, and plain radiography and thereby allow full characterization of this uncommon spinal injury. Characteristic components of the injury include: centripetally oriented disruption of the vertebral body, unilateral or bilateral laminar fractures that abut the spinous process, marked anterior wedging, vertically oriented vertebral fracture emanating from the basivertebral foramen, increased interpediculate distance, and significant spinal canal narrowing by characteristic retropulsed fragments. Nearly all bursts occurred from T9 to L5; double bursts were present in less than 10% of cases. The usually present neurologic deficit nearly always corresponded to the level of the burst rather than to the frequently found noncontiguous associated spine fracture. Recent literature suggests that these complex fractures, which were initially thought to represent stable injuries, are often unstable. A subcategorization of burst fractures and their variants is proposed to explain this instability. An approach to the radiographic diagnosis of the spinal burst is proposed, and plain film clues to distinguish the burst fracture from the more common compression fracture are discussed. Representative cases are illustrated.
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The causes of commonly occurring diagnostic oversights in the multiple injured patient are reviewed. A systematic approach to the multiple injured or unconscious patient is offered which includes a standard series of radiographs, "a trauma survey", and knowledge of commonly associated injuries. The identification of certain skeletal injuries should automatically suggest the possibility of other associated skeletal, visceral, or vascular injuries. Oversights could be significantly reduced by obtaining a standard series of radiographs, specifically looking for evidence of commonly missed injuries and always considering the possibility of frequently associated injuries.
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In a review of 17 surgically proven cases of acute traumatic diaphragmatic hernia, a nasogastric tube had been inserted preoperatively in eight. In six of these patients the tube followed a characteristic course, indicating the diagnosis of gastric herniation into the left hemithorax. In four cases the passage of the tubing established the diagnosis; in the other two cases the diagnosis was suggested by plain films alone, but subsequent passage of the nasogastric tube provided confirmation.
Dislocations at the carpometacarpal joints are uncommon and can be overlooked due to the subtle nature of the radiographic findings. The diagnosis requires a proper understanding of the normal radiographic anatomy of the carpometacarpal joints. To aid in our understanding of the injury, anatomic dissections of the hand were performed. From these, we drew several conclusions about the mechanism of injury. Diagnostic criteria were then developed and applied in the review of a series of CMC dislocations. The incidence and diagnostic characteristics are presented. A systematic approach emphasizing the posteroanterior view and utilization of the parallel "M", principles of parallelism, symmetry, overlapping articular surfaces, and a distinct cortical rim are presented.
The results of plain film radiography and arthrography in diagnosing loosening of a prosthetic component after total hip arthroplasty were correlated with surgical findings in 31 patients who required surgery because of hip pain. The accuracy of arthrography in diagnosing component loosening using 5 ml of contrast material was 51%, and the accuracy of plain radiography was 69%. An accuracy of 92% was achieved using a modified arthrographic technique in which the pressure in the joint was recorded after injection of contrast material and while the patient walked to ensure that it was comparable with the pressure that caused the patient's pain prior to the study. Three per cent of the arthrographic studies using this technique were false negative and 5% were false positive.
Dislocations of the carpometacarpal (CMC) joints are rare injuries which often have subtle radiographic findings that may be overlooked. A systematic approach for evaluation of the carpometacarpal joints is developed from analyzing the radiographic findings in 17 cases of CMC dislocations at the fourth and fifth CMC joints. Principles of parallelism, symmetry, overlapping articular surfaces, indistinct cortical rim, and parallel M lines are used in this evaluation. Ten patients had combined fourth and fifth CMC joint dislocations and seven had solitary dislocations at the fifth CMC joint. Most of these CMC dislocations are dorsal (71%). In combined fourth and fifth CMC joint dislocations, loss of parallelism and symmetry is observed at the fourth CMC joint with overlap identified primarily at the fifth CMC joint. Fracture of the fourth metacarpal base is often an associated injury. In solitary fifth CMC dislocations, slight ulnar offset of the fifth metacarpal on the hamate is the most consistent finding in association with loss of parallelism, symmetry, and overlap. Fracture of the radial margin of the fifth metacarpal base is often observed with solitary fifth CMC joint dislocations. A systematic approach and establishing the diagnosis from standard radiographic views is emphasized.